| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
802 |
795 |
$39K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
529 |
527 |
$17K |
| D1110 |
Prophylaxis - adult |
813 |
808 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
81 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,462 |
1,254 |
$5K |
| D0274 |
Bitewings - four radiographic images |
1,029 |
1,023 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,009 |
999 |
$1K |
| D1330 |
|
1,014 |
1,004 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
63 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
1,307 |
1,292 |
$906.55 |
| D1120 |
Prophylaxis - child |
38 |
38 |
$126.00 |
| D0180 |
|
12 |
12 |
$0.00 |